Question | Indicator (scoring applies to individual domains) | Alternative | |
Functional status | |||
Activities of daily living (ADLs) | Bathing, dressing, toileting, transferring, maintaining continence, feeding | Able to complete without assistance; able but with difficulty; unable to complete without assistance | |
Instrumental ADLs (IADLs) | Using the telephone, shopping, preparing meals, housekeeping, doing laundry, using public transportation or driving, taking medication, handling finances | Able to complete without assistance; unable to complete without assistance | |
Visual impairment | |||
Do you have difficulty driving, watching television, reading, or doing any of your daily activities because of your eyesight, even while wearing glasses?[1] | Yes indicates positive screen | Snellen eye chart | |
Hearing impairment¶ | |||
Is your age older than 70 years? | 1 point | Alternative is Audioscope[2] | |
Are you of male gender? | 1 point | ||
Do you have 12 or fewer years of education? | 1 point | ||
Did you ever see a doctor about trouble hearing? | 2 points | ||
Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person whispers to you from across the room? | If no, 1 point | ||
Without a hearing aid, can you usually hear and understand what a person says without seeing his face if that person talks in a normal voice to you from across the room? | If no, 2 points | ||
≥3 points: positive screen | |||
Urinary incontinenceΔ | |||
Have you had urinary incontinence (lose your urine) that is bothersome enough that you would like to know how it could be treated? | Yes indicates positive screen | ||
Malnutrition | |||
Have you lost any weight in the last year?[3] | Loss of at least 5% of usual body weight in last year indicates positive screen[3] | ||
Gait, balance, fallsΔ | |||
Have you fallen two or more times in the past 12 months? | Any yes response indicates positive screen | ||
Have you fallen and hurt yourself since your last doctor's visit? | |||
Have you been afraid of falling because of balance or walking problems? | |||
Depression◊ | |||
Over the past two weeks, how often have you been bothered by: | Response score for each:
Total ≥3 points: positive screen | ||
Little interest or pleasure in doing things? | |||
Feeling down, depressed, or hopeless? | |||
Cognitive problems | |||
Three-item recall[4] | <2 items recalled indicates positive screen[4] | ||
Clock-drawing test[5] | Any of the following errors indicate positive screen: wrong time, no hands, missing numbers, number substitutions, repetition, refusal[5] | ||
Environmental problems | |||
Home safety checklists[6] |
* All except the Snellen eye chart, Audioscope, and evaluation for cognitive problems can be assessed by self-report using questionnaire.
¶ Questions and response indicators are from the National Health and Nutrition Examination Survey (NHANES) battery.[7]
Δ Questions and response indicators are from the ACOVE-2 Screener.[8]
◊ Questions and response indicators are from the Patient Health Questionnaire-2.[9]Reproduced with permission from: Reuben DB. Medical care for the final years of life: "When you're 83, it's not going to be 20 years." JAMA 2009; 302:2686. Copyright © 2009 American Medical Association. All rights reserved.
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